Assessing prognostic documentation and accuracy among palliative care clinicians

Abstract

Background: Prognostication is an important element of palliative care consultations. Research has shown that estimated survivals offered by clinicians are often inaccurate; however, few of these studies have focused on the documentation and prognostic accuracy of palliative care providers.

Objective: Our aim was to determine whether palliative care clinicians document specific estimates of survival in the electronic medical record and whether these survival estimates are accurate.

Methods: We retrospectively analyzed 400 consecutive, new palliative care consults at an urban, academic medical center from October 1, 2009 to December 31, 2010. Descriptive statistics were used to summarize patient demographics, median patient survival, documented estimated survival, agreement between estimated and actual survival, and agreement differences among disease groups.

Results: The inpatient consult note template was utilized by the clinicians in 94.2% of the patients analyzed, and 69.4% of the patients analyzed had a specific survival estimate documented. Of the patients with specific survival estimates documented, 42.6% died in the time frame estimated. Weighted kappa coefficients and Kaplan survival estimators showed fair to moderate agreement between actual survival and estimated survival offered by palliative care clinicians. Survival groups with the shortest prognosis had the most accurate estimates of prognosis. Cancer had the least agreement between estimated and actual survival among disease types. Overestimation of survival was the most common prognostic error. Use of a template resulted in significantly greater documentation of a specific estimated survival.

Conclusions: The prognostic accuracy of palliative care physicians in this study was similar to physician accuracy in other studies. Trends toward overestimation were also similar to those seen in previous research. Use of a template in the electronic medical record (EMR) increases documentation of estimated prognosis.